Basic Information
Provider Information | |||||||||
NPI: | 1003100504 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE BACK CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2222 S HARBOR CITY BLVD | ||||||||
Address2: | SUITE 610 | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329015594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217237716 | ||||||||
FaxNumber: | 3217230604 | ||||||||
Practice Location | |||||||||
Address1: | 2222 S HARBOR CITY BLVD | ||||||||
Address2: | SUITE 530 | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329015594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217237716 | ||||||||
FaxNumber: | 3217230604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2011 | ||||||||
LastUpdateDate: | 07/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOPEZ | ||||||||
AuthorizedOfficialFirstName: | KATRINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 3215411537 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 225700000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 99949 | 01 | FL | MEDICARE | OTHER | 040225700 | 05 | FL |   | MEDICAID |